VR Based Psychotherapy with Dr. Aaron Williams

Introduction and Guest Presentation

Aaron: when I first started this using VR, a lot of it came down to sort of along the lines of what you’re saying, normalizing what it is. And highlighting what it is versus what it isn’t. It’s an immersive simulation experience that allows you to have the ability to connect with some potentially challenging situations, but you also have the ability to exit it really quickly if it’s too much. 

So you’re going to put on this headset and you’re going to feel kind of weird and it’s going to seem kind of silly, but believe it or not, your brain’s going to make some sense of it. And it’s probably going to respond.

Bruce: welcome to the Future of Psychiatry podcast, where we explore novel technology, new innovations in mental health. I’m your host, Dr. Bassi, an addiction physician and biomedical engineer. Today, we’re going to be focused on VR based psychotherapy. And we’re here with Aaron Williams, who is the chief behavioral health officer at Barbour Community Health Association, West Virginia. And he uses VR based psychotherapy in his practice. Welcome.

Aaron: Thank you.

The beginnings of the use of VR

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Bruce: So tell us a little bit about yourself and how you incorporate VR into your practice. 

Aaron: Yeah, so I’m a as you mentioned, chief behavioral health officer at an FQHC, so federally qualified health center. And we serve a rural Appalachian underserved population, providing a whole range of services and then the behavioral health department, that predominantly consists of things such as outpatient therapy, psychological testing, medication management, some of those types of things.

I’m also a licensed clinical psychologist, and in the context of being a psychologist, I do a combination of therapy and assessment. Approximately, I want to say like four years ago, if I’m remembering correctly, prior to the pandemic, I started to learn a bit more about virtual reality as a modality for therapy services and started to utilize it with some of the patients that I had where their technology capabilities allowed for that and where the clinical concerns were indicated for that.

As an example, I, have had some people that, for example, have agoraphobia type symptoms, and so they wouldn’t be easy getting them into the office and also being in a rural location, it makes it sometimes challenging to have– we have some transportation barriers, getting people to the office.

Some of my first introductions utilization of VR was actually through a tele platform like we have here now sending VR simulations to a person’s smartphone with some goggles that they could put their smartphone into and then having them practice things such as leaving the home.

And it was a really fascinating and in a really beneficial way of being able to do kind of in vivo interventions, or at least as close to that as I could do while recognizing the limitations of the patient being able to come here. Again, being rural the exposure opportunities are pretty limited here.

And so it was, that was kind of my first foray into that was through that type of intervention. And I now use it probably a little more broadly in both a virtual and in a clinic setting.

Bruce: So you have individuals who are there with you in person and also you do administer it remotely like you’re talking about.

Aaron: Yeah. So it’s, a combination of both. I typically only use the remote one for people that either have a significant psychological barrier or logistics barrier to coming to the office. But I’ve been able to use it with some good outcomes in both instances.

In person vs VR

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Bruce: Are there any differences that you notice in terms of how you manage their symptoms or helping them to feel relaxed? That is easier for you in person? Or do you already know most of the patients that you’ve already met them in person so then when you do see them once virtually, you already kind of have that relationship with them.

Aaron: Yeah, I, don’t believe in any of the cases I can think of, any of the patients I’ve seen, we started just right out the gate with VR. I think they all were people that over the course of establishing rapport and identifying clinical areas of need, we would come to a point in our therapeutic discussion of here’s this modality that I think might potentially help you.

In addition to the 1 case, I can think of off top of my head, where maybe we started pretty early in the process with somebody that had just been in an automobile accident and they were afraid to drive. And so we talked about the idea of putting them behind a steering wheel in a kind of a safe, therapeutic space, and just getting them acclimated to sitting behind the steering wheel, noticing what they were feeling physiologically, noticing the emotions and the thoughts that they were having that were accompanying that.

That’s the only situation, where I can think of where, we started with that as kind of the introductory modality. Most of the other situations were getting to know someone clinically and then kind of pivoting to that as a means of intervention.

Introduce the patient to the VR

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Bruce: Interesting. So, individuals come to you, I’m sure, probably a little bit hesitant, skittish about using VR, questioning the efficacy. My experience has been that people become a believer pretty quickly and really underestimate the power of it. They realize that it’s created quite a powerful bodily reaction in them. And it’s just a device that they’re wearing in front of their eyes. 

And they quickly become a believer and put that skepticism aside, but you do need to get that first taste of it, though. 

What has been that conversation like to try to talk to somebody about explaining the benefits to them, if they might have to pay a little bit of money to buy the mount for them to put the phone into maybe the phone too, if they don’t have a phone yet, or the headset, if they don’t have a headset, but talk to me about how you are convincing or communicating to an individual who maybe has no experience to VR. 

Aaron: So a couple of things with the logistics that you mentioned that there are some really interesting kind of shortcuts around, the need for things like capabilities. And so, like, I have this here, yes, and these are nice because they’re all of maybe like 10 bucks, if I remember, maybe a little bit more.

But if you have the smartphone, it’s an easy conversion. Being that I’m in an FQHC. One of the things , that we are typically serving are patients that are very under resourced and lack a lot of fluency when it comes to mental health, give you an idea. When I first came to this county the licensing board told me that I was the 1st doctoral level psychologist to work in the county full time in the history of the county.

So we started at a very low base. We’ve done some other, the major university that is in my state did a telepsychiatry grant and the outcome of their telepsychiatry grant was we were introducing telepsychiatry. We were introducing psychiatry to give you an idea. So, like, the fluency is pretty low.

So it was 1 of these things when I 1st started looking down this path. I questioned whether or not people would be receptive to this because I’ve worked in urban areas and right now I’m in a very rural area and I think certain comfort levels with technology are a little different sometimes in those settings, depending on how much it’s a part of your everyday life.

And so when I first started this using VR, a lot of it came down to sort of along the lines of what you’re saying, normalizing what it is. And highlighting what it is versus what it isn’t. It’s an immersive simulation experience that allows you to have the ability to connect with some potentially challenging situations, but you also have the ability to exit it really quickly if it’s too much. 

And I think so for a lot of people, I think the concern was, is that I’m going to put this on. I’m going to get so overwhelmed and I’m going to be flooded. And I have no idea what to do. And what we did is we kind of went through the software, went through the hardware. I would show them as much as I could without compromising the clinical integrity of it.

I tried to be also fairly plain language as a clinician. So like the vocabulary that I’m using here is like, so you’re going to put on this headset and you’re going to feel kind of weird and it’s going to seem kind of silly, but believe it or not, your brain’s going to make some sense of it. And it’s probably going to respond. 

And so if I am trusted, and I’m fairly low key, but I’m informative and I’m not trying to make it overly complicated. I find that the people that I work with typically will align with it pretty well. It’s not for everyone, and there’s some people that I think there´s still a learning curve and some of those people I sometimes need to spend extra time with in prepping or educating, but I was pretty surprised at how quickly people took to it and how effective it was.

Really kind of creating some situational shortcuts that, you know, rehearsal alone or role playing alone, or sending someone out and [00:08:00] saying, hey, go to this public setting and try this thing. Sometimes the ability to go from the exercise to the execution. Is really challenging and this is a great intermediary step as far as I’ve been able to utilize it.

And then I add to that a little bit with I’m going to guess you might be familiar with the name Skip Rizzo and kind of going through this. He’s a big name in this. I went to a couple different conferences. He’s 1 of the originators of the utilization of this in the VA systems for people with PTSD and combat related traumas and I was fortunate enough for a period of time to be able to consult with him briefly. And 1 of the things he was really interested in was. How will this apply to a rural population? We know how this will work with people in urban settings and some of the major cities, but tech fluency and tech comfort tends to be a bit higher in those regions. So I think coming in with a little bit of some education from him, having had some exposures and training and then me taking all of that and acclimating it to the audience and the population that I work with really helped to, I think, shortcut the comfort curve in utilizing this and people kind of buying in, so to speak.

How to measure anxiety in a remote VR session

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Bruce: let’s attempt to glean some nuggets from you regarding the actual session itself. Say you’re in a session and an individual maybe doesn’t have as much awareness of their bodily representation of anxiety and you’re working with them remotely. How are you measuring their units of distress? How often are you asking them, prompting them to rate that on a 1 to 10 scale if you’re doing that? Or are you Visually seeing how their body’s reacting. And if you have any examples, that will be really helpful.

Aaron: Yeah, all the above. So one of the, especially with the tele modality of it, one of the really interesting things is obviously we can do split screen type of presentations. And so on one half of the screen, I would have a visual of the patient, the camera showing them with the headset on. And so I’m able to kind of monitor like what they, how they appear as though they would appear in front of me.

So I can notice things like changes in facial expression. I can notice muscle tension. I can notice, you know, posture, rigidity whatever cue might be there to give me a sense on. They’re going through something right now. Enough to potentially ask and just say, Hey, what are you feeling at the moment?

But the other is that the devices themselves, at least the Amelia one that I utilize has a fairly non invasive yet visual ability to ask a question and to say, you know, what are you feeling right now? Or what’s your subjective units of distress? And we go over, how to consider SUDs prior to utilizing the software.

In fact, a lot of the people that I have utilized this with, I might have also utilized some EMDR techniques with. And EMDR also uses a SUD scale, subjective units of distress. So that concept carries over well from EMDR into this. But if they don’t, I explained that I can give them a sense on– this is your, rating of yourself. What is it that you’re noticing? You know, here’s your 0, here’s your 10. where does this fall? 

And so the visual representation, the self report, my observations, and then we haven’t really gotten into this too much yet, but the galvanic skin response in heart rate, there are some kind of add ons that we could do with that.

We haven’t been able to do it as of yet in a traditional VR context. There is one spot where I was able to add on another layer, and I can’t say I’ve done a lot with this, but we also have TDCS transcranial direct current stimulation, so neurofeedback neurostimulation, and we were able to do, with at least one of my patients, a combination of VR, And kind of noticing how they were responding on the 20 channel EEG in real time.

The challenges of that– the data collection on, it’s fascinating– the challenges of it though are that it’s, it’s really hard to get all of those pieces together and have all the people I need to together to make that all, you know, pull off relatively well, but I do think there is some promise in that.

I think the ability to maybe have even like real time neurological data or at least the EEG data could be potentially useful down the road with this. So dabbled a little, but I can’t say I’ve done anything with it heavy duty.

Bad patient experiences and how to prevent them

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Bruce: When I prescribe a medication, obviously there’s instances when a medication just didn’t work for somebody. They had a really poor experience with it, a side effect that they weren’t expecting, and, so to speak, it could have backfired starting it. Have you had that experience where a patient just really didn’t take well to the VR experience, and what did you learn about that process? That maybe you incorporated into subsequent, patient encounters. 

Aaron: Yeah you know, again, thinking about parallels with EMDR, I think there are some, and one of them is, the idea of doing preparatory exercises. I had learned from a couple early utilizers that there was, I would say two or three that initially felt okay with the modality, but we would amp something up, whether it’s the stimulus or it was, maybe shifted from a, like a low threshold stimuli to a, maybe a more moderate stimuli.

And you would see that they didn’t maybe digest that shift very well. And that would include kind of a lot of the fight or flight responses. You might anticipate seeing for someone getting over aroused or overstimulated. And so 1 of the things that it really hit home to me was that I, make a point of prepping people in multiple ways and also in some like mindfulness type training. And so we do things like, for example, in EMDR, there’s a calm, comfortable place exercise. And it’s basically this souped up visualization where you’re utilizing multiple points of sensory information.

So, you know, if you pick the beach, it would be, what are you seeing in front of you? What are you feeling texturally? What’s the smells and very grounding oriented interventions. What I’ve started to do is that when I utilize the VR before I even go into this I’m trying to gauge a couple of different things.

1 is what’s their distress tolerance? So, like, for example, individuals that might have let’s say PTSD or significant PTSD type responses also individuals that have things like borderline personality disorder, where emotional regulation, once it’s activated, becomes a real challenge. I’m usually doing a bit more kind of grounding homework exercises.

I’m trying to vet that in the very beginning . If somebody is really struggling with the ability to self regulate once they get stimulated, we probably hold off on VR at least for a period of time until we can get to a point where we’re both very comfortable that if escalation does occur there are some pathways to bringing it back to a level where a person feels emotionally and psychologically safe.

But that would probably be the things I learned the most from the missteps or the learning curve on my end in the beginning. That’s for sure.

How a clinician can get started with VR for the first time

Bruce: What types of challenges have you experienced with working with your patients with this modality and how have you overcome them maybe for somebody who’s thinking about using VR for the first time, but is a little bit timid on using that tool 

Aaron: yeah, I think there’s, a variety of things that I think help with that. 1 is becoming familiar with it. Not only as a clinician, but I would encourage somebody to take it as a patient or as a participant. Because you’re gonna have a much better experience and sense on what a person is exposed to thinking, feeling there–

I’ll give you an example. I’m not the biggest fan of heights. I have some acrophobic type symptoms. And so I threw myself in a glass elevator in 1 of them, and you feel it like, when you connect with it. Even though, you know, it’s a simulation, you’re still going to have the response and, it’s one of the things that Dr Rizzo had mentioned as well was that, yeah, your brain logically may know this isn’t real, but it’s still going to respond largely as though it does and you can feel that, I can objectively say, I know I’m safe, but at the same time, I was still having the gut sensation of being up really high as I would have if that was real.

So I think understanding kind of the power of the modality, understanding what somebody might experience is a big part of it. I think also getting to a point with not only the interface and understanding how to utilize it but understanding some of the theory behind it. I wouldn’t suggest you just try to go into this without a bit of homework.

I, you know, made a point of attending a few different CE events. I did some research to understand the strengths and limitations of this model had safety planning in place. So again, I’m not, doing this similar to like some of the things you would consider in the safety end with telepractice, I’m considering with this as well.

 

I don’t want to put somebody in an activating situation and run the risk of them suddenly hitting the off button on everything and me wondering what happened here. Are they okay? Am I having to call 911? So, like, making sure you have all those safeguards in place and you have a process and you know how you’re going to implement this, you know, the strengths and limitations of the modality.

Those would be the things that come to mind as like early on. I think one of the things that’s unique about this when I think about it compared to other modalities is how people in the very beginning when they first connect with it might go, this is silly. And then a few minutes later go, Oh, my goodness, I’m really responding , there is an interesting kind of disconnect where I don’t think , that you necessarily recognize the strength of the immersion until you’re there for a little, like in the very beginning, you’re just seeing images and maybe some sounds and you might think, okay, this is like I’m watching a movie, but the more that you’re in it, the more it becomes your reality. 

And it can be kind of subtle, like where suddenly a person goes, you know, like , if I remember correctly, there’s one simulation I used that was being on an airplane with someone who had never flown before. And they’re like, oh, this doesn’t look real. This person next to me is completely fake. I look out the window. I don’t see much of anything. And then like, probably a couple minutes later, we did a takeoff and there’s a little bit of turbulence. And they were feeling it and they noticed they were feeling it and it was this interesting kind of like recognition and reaction on their part where they started laughing, but it was almost that, like, nervous laughter , a little embarrassing and a little kind of caught unawares almost in some ways, like, you know, they thought they had this figured out. And yet . It didn’t happen that way.

Those are the things I think as a clinician first entering this space that really stand out to me as being important considerations when you approach this conceptually

Using VR for psychosis or substance use disorders

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Bruce: Have you used VR yet in other, so to speak, off the beaten path options other than for exposure therapy or anxiety? Because I do see a pathway here where VR can potentially become so commonplace in the treatment of OCD And anxiety in some way, shape, or form for patients down the road.

What about for depression or psychosis or substance use? What do you think is the next runner up after anxiety and OCD for VR to become more of an established presence

Aaron: I honestly think there’s space for probably all of those. So, taking some of the examples that you gave when I think about something like depression, one of the interesting things with the VR software, especially with the more recent updates, is you can kind of notice visual tracking and so like you can kind of see the vision plot of what somebody has as they are engaging or interfacing with the world around them in the VR simulation.

 

And it tells me some things on like, what is it that they’re focusing on? What are they noticing in that environment? Are they showing, ability to have some fluidity and moving throughout and scanning their environment? Or they just locked in on one particular element of it? I think that I could see this also kind of falling into a realm of somewhere between therapeutic and video games where there’s a reward system, operant conditioning type of effect going on. And for at least some of the people that I meet with, they would much rather play a game of– when you mentioned OCD– there’s an individual that I work with that tends to have a high degree of fear OCD behaviors, but also just generalize fear. And there is this 1 platform, or this 1 simulation that if you scan all the dark corners of the scary room, you would get points for it. And so it became kind of almost this gamification of a therapeutic technique, and it also let that person see, oh, my score is going up, so I must be doing better.

And I not only that I see that being effective there, but I could imagine that being effective in a variety of mental health context, substance use in particular, when I think about like the dopamine disruptions and the challenges that are there with the reward system. Anything that gets some motivation is potentially a step in the right direction, providing it’s a healthy motivation.

So substance usage, I could certainly see for that as well. I think it’s also like I look at something like psychosis and I think you’d have to have someone with some pretty good insight and some pretty good skills, but I could see something like how do you take something that is questioning your sense of reality and become maybe a better communicator or a person that can outreach about it better?

An example is, that when I work with some individuals with psychosis, I might be their only form of reality testing that they have in their life. So, that people, for example, bring in radios where it’s playing static in the background and say, I can hear someone yelling at me or talking to me and, can you hear that?

I don’t hear it and sometimes that’s reassuring to them to be able to go, "okay, probably just my condition. Probably just my mental health in that moment. If somebody though, isn’t at that level through other modalities. I think this could be a really ingenious way of practicing that in real time.

I could throw something up on a screen and it could be a little odd. And, you know, whether it’s just like, maybe some sensory disruption, or it’s something that maybe aligns with something that they have in their manifestation of psychosis. And if it’s not too activating, but it’s familiar enough, can I get them to report it?

Can I get them to get comfortable telling me about it? So I think it can even normalize some things in that regard.

Use of technology in mental health purposes

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Bruce: I really like that idea of blending in psychosis treatment. I think that is definitely under recognized, under appreciated, under treated and that could be one area that really gains a little bit more traction and, and um, acknowledgement in the VR world as well. That brings me to another question I had. Is there anything that really excites you in this field that you’re looking out for, hoping that arrives soon? 

 

Aaron: I’m very excited about technology when it comes to the utilization of it for mental health purposes, but there are some sometimes questions and concerns that I think sometimes can be valid. For example, anytime I’ve ever vetted a tech device, I’m always asking about what data are you collecting? What’s the privacy level on this? This being used outside of, is this kept on a server or is this kept on my computer? So, if it’s done responsibly I could see some really exciting things of an interfacing between AI and this and what I think about, for example, is that right now, the simulations, I think they are effective, but I don’t think they’re very dynamic.

And as much as I can add dynamism to it, I will try to as much as the features allow, but wouldn’t it be really interesting if you had like somebody with an autism spectrum disorder or somebody that has a personality disorder or somebody that has psychosis even and you had them interfacing with an AI bot in a simulation like that where you can still address elements of the parameters, but like, how do you express intimacy? How do you express connectedness? Are you reading the person aside from you? What type of sensations are you getting from? Referencing back to Dr. Rizzo, I believe in one of the presentations that I had attended that involves some elements of, kind of simulations and VR, that there was a bot that the VA use that acts like a veteran and, talks like a veteran.

And it’s a little more of a humanizing way to almost do an intake through an automated system. So it’s like, hey, buddy, what’s going on with you? And it starts to feel a little bit real in some ways. And I think as long as that’s done with a high degree of control and sensitivity and there’s good research behind it, it will be fascinating.

And I think incredibly effective if some of the more complex social interactions could be replicated in this platform and that immersion piece I think could go beyond again role playing alone or just sending someone out and say, try this when we don’t know what the outcomes going to be. Well, here I can control elements of the outcome.

So that way, if somebody completely flounders or has a really hard time with it. I don’t necessarily have to give them the harshest response, whereas, and if I send them out into public and say, try this thing, I don’t know what the response is going to be. And sometimes when you were trying to build skills, I think about things like scaffolding.

You want to have success. Before you try that next goal, this would really help for doing that with some like socially complex and nuanced situations.

Possibility of a VR certification in psychiatry

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Bruce: Interesting. Do you think that eventually VR modalities of providing psychotherapy would become a certification or a subspecialty within the discipline of psychology or psychiatry?

 

Aaron: I think if it continues to be invested in and investigated, and we continue to see research on it. Absolutely. Because I think we are talking about. Some unique elements within this particular modality. One is the degree of immersion. And so when we think about immersion, we are kind of turning up the volume on a lot of these sensory experiences.

And I, think, by extension, having good training on understanding what that means, how, physiologically the response also complements some of the imagery that we’re giving. It seems to me, at least based on my interactions with this modality, that when it hits, it hits a bit more potently than any other types of modalities in this space that we’re using, whether it’s exposure or imaginal, short of the actual thing that a person may be having a response to.

I also think, like just general, The more that we have specialties and, have guidelines and practice, the more you legitimize some of these things. And I do think there’s a segment of the population that you have to convince that this isn’t just hokey and gimmicky, and that there’s, you know, there’s some value behind the modality.

It’s not just like, what new bells and whistles can I bring into a therapy situation? So, when we have those types of things like standards of practice or, like a blueprint for, how to do this and, there’s some research behind what are the most efficacious ways to do this, then I think it just helps the legitimacy of anything.

That’s an emergent way of, practice or, emergent technology intersecting with practice.

Bruce: That’s awesome. I really appreciate your insights. We went a little bit over time, but I think that was because you explain things really well. I think that was one of the best conversations that I’ve had about this. So, really appreciate that. 

That’s it for this episode. I’d appreciate it if you please like and share this podcast with your colleagues. It’d be especially helpful for us. If you’d like, please leave us a rating on your favorite podcatcher. If you’re a clinician, I developed a course on how to start a private practice. And for patients, I’ve also developed a course on acceptance and commitment therapy and cognitive behavioral based therapy lessons for treating and helping anxiety.

You can find all these on our website as well. as well as the show notes and resources for each episode. Thank you so much, and I’ll see you in the next episode.